Arm Contouring: Review and Current Concepts

Arm Contouring: Review and Current Concepts Abstract Arm contour improvement is a desired goal of the massive weight loss and the aging population who want to maintain the arm aesthetics. Brachioplasty is a growing and safe procedure to improve the arm contour and different approaches and innovative treatment options have been described since the 1930s. This paper reviews the relevant literature in arm contouring including surgical and nonsurgical procedures used to aesthetically improve the arm. A comprehensive literature review was performed using the words “brachioplasty,” “arm lift,” “arm contouring,” “arm liposuction,” “noninvasive arm lift,” “minimally invasive arm lift.” Commonly used techniques, classification systems, and procedure outcomes are described. The review demonstrated that there are several methods to accomplish good arm contouring. There is no consensus about the best incision type and location, but the classification systems help guide treatment. Assessment of fat excess, skin excess, and location of the deformity (proximal, entire arm, arm and chest) help determine the best approach including liposuction only, skin resection only, a combination of liposuction and excision, or even the use of nonsurgical devices. Infection, hematoma, and unsatisfactory scars are the most commonly reported complications. Brachioplasty is a growing procedure and can be performed with low complication rates and good patient satisfaction. Classification systems stratify deformities to the ideal treatment but no studies have shown the superiority of any technique. Nonsurgical fat removal and skin tightening of the arms are promising procedures for selected patients and higher levels of evidence are needed to show clear indication for different technologies and devices. Learning Objectives The reader is presumed to have basic knowledge and understanding of arm anatomy pertinent to arm contouring procedures. After reading this review, the reader should be able to: Identify a suitable candidate for arm contouring procedures. Discuss common techniques and potential pitfalls of different arm contouring procedures including surgical and non-surgical modalities. Identify potential risks and benefits of arm contouring procedures. The American Society for Aesthetic Plastic Surgery (ASAPS) members and Aesthetic Surgery Journal (ASJ) subscribers can complete this Continuing Medical Education (CME) examination online by logging on to the CME portion of ASJ’s website (http://asjcme.oxfordjournals.org) and then searching for the examination by subject or publication date. Physicians may earn 1 AMA PRA Category 1 Credit by successfully completing the examination based on the article. The American Society for Aesthetic Plastic Surgery estimates a total of 24,622 brachioplasty procedures were performed in 2016, a fourfold increase since the year 2001.1 Also in 2016, the American Society for Metabolic and Bariatric Surgery reported approximately 200,000 bariatric surgeries and these numbers are estimated to continue to rise annually.2 As bariatric surgery becomes the surgical standard of care for the treatment of metabolic disease, it is logical to assume that the numbers of body contouring procedures will continue to grow. Arm contour improvement is a desired feature not only of the massive weight loss population but also of the aging population who want to maintain the arm aesthetics. The objective of this paper is to review the relevant anatomy, surgical techniques, and outcomes in brachioplasty and minimally invasive arm contouring procedures. Historical Perspective As the field of body contouring surgery parallels the staggering numbers of bariatric procedures done worldwide, the techniques addressing the excess skin and fat of the upper arm continue to evolve. The evolution and aesthetic refinements in technique have made this surgery a safe procedure, due to a better understanding of anatomy, preventions of potential nerve injuries during resection, and several technological advancements. The idea of sculpting the arms of excess skin and fat is not novel. In the 1930s Thorek popularized an elliptical excision of the medial upper arm as the preferred technique for brachioplasty at that time.3 Aesthetic arm contouring refinements were then published by Correa-Iturraspe and Fernandez in 1954.4 In the 1970s Lewis modified the procedure by adding a Z-plasty to address issues of scar contracture, and in the same decade, Pitanguy added the extended approach of the axillary and arm skin excess through one single incision.5 In 1995, Lockwood published his landmark article regarding the superficial fascial system as a supportive structure of the arm and its role in arm contouring surgery, concepts that have since become one of the principles applied to brachioplasty procedures.6 In 1998, Teimourian and Malekzadeh published the first classification system of the degree of severity of arm deformity with a corresponding surgical treatment that could provide the best aesthetic result.7 Relevant Anatomy The youthful appearance of the arm depends on skin quality, adipose tissue distribution, and muscle shape. The skin of the medial arm is thinner than other body parts and therefore prone to early wrinkling. The subcutaneous layer is divided into superficial (alveolar) and deep (lamellar) layers, and the deeper layer is more prone to fat accumulation than the superficial layer, mostly in the posterior arm.8 The superficial fascial system (SFS) described by Lockwood supports the posteromedial arm as a sling, and is contiguous with the clavipectoral and axillary fascia. This mechanism fails with aging or significant weight loss, leading to ptosis of the posteromedial arm. Deeper into the subcutaneous layers, muscles and deep neurovascular structures are involved by the deep fascia. Just superficial to the deep fascia are the medial brachial and antebrachial cutaneous nerves, major sensory nerves that innervate medial arm, the elbow, and the proximal forearm. These sensory nerves arise from the medial cord of the brachial plexus and travel superficially to the deep fascia along the basilic vein in the distal third of the arm. Sensory branches are most often encountered 7 to 14 cm proximal to the medial epicondyle and can be easily damaged during dissection of the distal arm (Figure 1). Careful superficial dissection in this location, leaving a layer of fat over the deep fascia, can help prevent nerve injury.9-11 The lymphatic system follows the course of the venous systems and drains into the axillary lymph nodes.11 Superficial dissection can also help preserve of the lymphatic network and improve seroma formation. Figure 1. View largeDownload slide Diagram showing the arm anatomy relevant to brachioplasty, which includes the estimated location of the neurovascular structures including the cutaneous nerves. Red: brachial artery (deep plane); blue: basilic vein, the anatomic landmark for medial antebrachial cutaneous nerve identification. Figure 1. View largeDownload slide Diagram showing the arm anatomy relevant to brachioplasty, which includes the estimated location of the neurovascular structures including the cutaneous nerves. Red: brachial artery (deep plane); blue: basilic vein, the anatomic landmark for medial antebrachial cutaneous nerve identification. Preoperative Assessment A thorough history and physical examination, including evaluation of the whole circumference of the arm with the arms abducted and elbows flexed at 90 degrees to obtain maximal tissue relaxation. Establishing clear patient expectations and scar tolerance is paramount for brachioplasty, since the scar can be very visible for several months to years after surgery. Preferred scar location can be discussed with the patient, and some authors advocate drawing a preview of the scar on the arms a few days before surgery to help patients have realistic expectations about location and length of the scar.12 Frontal, oblique, and posterior views should include the upper trunk since deformities of the arms can extend into the axillary and lateral chest area (Figure 2). Figure 2. View largeDownload slide These photographs show a 39-year-old woman in standard (A) frontal, (B) oblique, (C) and posterior preoperative pictures for brachioplasty patient. Frontal, oblique, and posterior views should include the axilla and lateral chest wall to document laxity in those areas. Figure 2. View largeDownload slide These photographs show a 39-year-old woman in standard (A) frontal, (B) oblique, (C) and posterior preoperative pictures for brachioplasty patient. Frontal, oblique, and posterior views should include the axilla and lateral chest wall to document laxity in those areas. Classification systems are helpful to guide treatment selection during preoperative assessment. It includes assessment of fat excess, skin excess, and location of the deformity (proximal, entire arm, arm and chest) and treatment options vary between liposuction only, skin resection only, a combination of liposuction and excision, or possibly the use of newer skin tightening devices. Table 1 shows the 3 most commonly used classification systems of arm deformities and strategy for treatment. Teimourian and Malekzadeh described the first classification system, dividing patients into 4 groups. Deformities and treatment escalade from group 1 to 4, from minimal to moderate adiposity, suitable for liposuction alone to traditional brachioplasty for patients with extensive laxity.7 Appelt et al expanded the classification system to include location of skin excess, and added the indication for extended brachioplasty to severe deformities encompassing the arm and lateral chest wall.13 El Khatib’s classification of brachial ptosis is similar to the previous ones but also includes measurement of the amount of skin laxity below the brachial sulcus from no ptosis to >10 cm to improve the strategy for treatment.14Figure 3 illustrates different groups of deformities. Table 1. Classification of Arm Deformities and Treatment Strategies. Adapted from Teimourian and Malekzadeh,7 Appelt et al,13 and El Khatib.14 Teimouriam and Malekzadeh Group Skin and fat excess Treatment I Minimal to moderate subcutaneous fat with minimal skin laxity Liposuction alone II Generalized accumulation of fat with moderate skin laxity Liposuction +/- axillary skin excision III Generalized obesity and extensive skin laxity Circumferential liposuction with proximal skin resection IV Minimal fat and extensive skin laxity Brachioplasty Appelt et al Group Skin and fat excess Treatment I Minimal skin, moderate fat Liposuction alone (UAL + SAL) IIa Moderate proximal skin, minimal fat Limited brachioplasty IIb Moderate entire arm skin, minimal fat Brachioplasty (possible L-shape extension) IIc Moderate arm and chest skin, minimal fat Extended brachioplasty IIIa Moderate proximal skin, moderate fat Staged liposuction or liposuction plus resection IIIb Moderate entire arm skin, moderate fat Staged liposuction or liposuction plus resection IIIc Moderate arm and chest skin, moderate fat Staged liposuction or liposuction plus resection El Khatib Group Skin and fat excess Treatment I Minimal fat deposit (<300 mL) with no ptosis Circumferential liposuction IIa Moderate fat deposit with grade 1 ptosis (<5 cm) Staged circumferential liposuction IIb Severe fat deposit with grade 2 ptosis (5-10 cm) Liposuction +/- axillary skin excision III Generalized obesity and extensive skin laxity Liposuction arm + short scar brachioplasty IV Minimal or no fat deposit with grade 3 ptosis Brachioplasty Teimouriam and Malekzadeh Group Skin and fat excess Treatment I Minimal to moderate subcutaneous fat with minimal skin laxity Liposuction alone II Generalized accumulation of fat with moderate skin laxity Liposuction +/- axillary skin excision III Generalized obesity and extensive skin laxity Circumferential liposuction with proximal skin resection IV Minimal fat and extensive skin laxity Brachioplasty Appelt et al Group Skin and fat excess Treatment I Minimal skin, moderate fat Liposuction alone (UAL + SAL) IIa Moderate proximal skin, minimal fat Limited brachioplasty IIb Moderate entire arm skin, minimal fat Brachioplasty (possible L-shape extension) IIc Moderate arm and chest skin, minimal fat Extended brachioplasty IIIa Moderate proximal skin, moderate fat Staged liposuction or liposuction plus resection IIIb Moderate entire arm skin, moderate fat Staged liposuction or liposuction plus resection IIIc Moderate arm and chest skin, moderate fat Staged liposuction or liposuction plus resection El Khatib Group Skin and fat excess Treatment I Minimal fat deposit (<300 mL) with no ptosis Circumferential liposuction IIa Moderate fat deposit with grade 1 ptosis (<5 cm) Staged circumferential liposuction IIb Severe fat deposit with grade 2 ptosis (5-10 cm) Liposuction +/- axillary skin excision III Generalized obesity and extensive skin laxity Liposuction arm + short scar brachioplasty IV Minimal or no fat deposit with grade 3 ptosis Brachioplasty SAL, suction-assisted liposuction; UAL, ultrasound-assisted liposuction View Large Table 1. Classification of Arm Deformities and Treatment Strategies. Adapted from Teimourian and Malekzadeh,7 Appelt et al,13 and El Khatib.14 Teimouriam and Malekzadeh Group Skin and fat excess Treatment I Minimal to moderate subcutaneous fat with minimal skin laxity Liposuction alone II Generalized accumulation of fat with moderate skin laxity Liposuction +/- axillary skin excision III Generalized obesity and extensive skin laxity Circumferential liposuction with proximal skin resection IV Minimal fat and extensive skin laxity Brachioplasty Appelt et al Group Skin and fat excess Treatment I Minimal skin, moderate fat Liposuction alone (UAL + SAL) IIa Moderate proximal skin, minimal fat Limited brachioplasty IIb Moderate entire arm skin, minimal fat Brachioplasty (possible L-shape extension) IIc Moderate arm and chest skin, minimal fat Extended brachioplasty IIIa Moderate proximal skin, moderate fat Staged liposuction or liposuction plus resection IIIb Moderate entire arm skin, moderate fat Staged liposuction or liposuction plus resection IIIc Moderate arm and chest skin, moderate fat Staged liposuction or liposuction plus resection El Khatib Group Skin and fat excess Treatment I Minimal fat deposit (<300 mL) with no ptosis Circumferential liposuction IIa Moderate fat deposit with grade 1 ptosis (<5 cm) Staged circumferential liposuction IIb Severe fat deposit with grade 2 ptosis (5-10 cm) Liposuction +/- axillary skin excision III Generalized obesity and extensive skin laxity Liposuction arm + short scar brachioplasty IV Minimal or no fat deposit with grade 3 ptosis Brachioplasty Teimouriam and Malekzadeh Group Skin and fat excess Treatment I Minimal to moderate subcutaneous fat with minimal skin laxity Liposuction alone II Generalized accumulation of fat with moderate skin laxity Liposuction +/- axillary skin excision III Generalized obesity and extensive skin laxity Circumferential liposuction with proximal skin resection IV Minimal fat and extensive skin laxity Brachioplasty Appelt et al Group Skin and fat excess Treatment I Minimal skin, moderate fat Liposuction alone (UAL + SAL) IIa Moderate proximal skin, minimal fat Limited brachioplasty IIb Moderate entire arm skin, minimal fat Brachioplasty (possible L-shape extension) IIc Moderate arm and chest skin, minimal fat Extended brachioplasty IIIa Moderate proximal skin, moderate fat Staged liposuction or liposuction plus resection IIIb Moderate entire arm skin, moderate fat Staged liposuction or liposuction plus resection IIIc Moderate arm and chest skin, moderate fat Staged liposuction or liposuction plus resection El Khatib Group Skin and fat excess Treatment I Minimal fat deposit (<300 mL) with no ptosis Circumferential liposuction IIa Moderate fat deposit with grade 1 ptosis (<5 cm) Staged circumferential liposuction IIb Severe fat deposit with grade 2 ptosis (5-10 cm) Liposuction +/- axillary skin excision III Generalized obesity and extensive skin laxity Liposuction arm + short scar brachioplasty IV Minimal or no fat deposit with grade 3 ptosis Brachioplasty SAL, suction-assisted liposuction; UAL, ultrasound-assisted liposuction View Large Figure 3. View largeDownload slide Diagrams illustrating different arm deformities. (A) Minimal skin laxity and no fatty deposits. Potential candidate for nonsurgical skin tightening procedure. (B) Moderate skin laxity in the proximal third of the arm with minimal fatty deposits. Potential candidate for limited axillary fold scar or a “T” pattern scar with the longitudinal limb limited to the proximal arm. (C) Moderate skin laxity and moderate fatty deposits. Potential candidate for a traditional brachial groove or bicipital groove brachioplasty and arm liposuction. (D) Severe skin laxity that extends into the lateral chest wall. Potential candidate for an extended brachioplasty. Figure 3. View largeDownload slide Diagrams illustrating different arm deformities. (A) Minimal skin laxity and no fatty deposits. Potential candidate for nonsurgical skin tightening procedure. (B) Moderate skin laxity in the proximal third of the arm with minimal fatty deposits. Potential candidate for limited axillary fold scar or a “T” pattern scar with the longitudinal limb limited to the proximal arm. (C) Moderate skin laxity and moderate fatty deposits. Potential candidate for a traditional brachial groove or bicipital groove brachioplasty and arm liposuction. (D) Severe skin laxity that extends into the lateral chest wall. Potential candidate for an extended brachioplasty. Surgical Technique There are many described techniques to accomplish a sound aesthetic result in brachioplasty and consequently there is no consensus on the ideal approach, scar placement, or short vs extended scar techniques. As shown on Table 1, a common guide for defining the ideal brachioplasty technique for different patients is the assessment of the amount of skin laxity and amount of fat excess. There are also variations on scar positioning and use of associated liposuction among different authors. The most common proposed techniques involve skin excision alone, excision associated with liposuction, or liposuction alone. These algorithms share similarities and aim to qualify the amount of skin and fat excess and correlate the different presentations with optimal surgical approaches. Preoperative markings are made with the shoulders abducted to 90 degrees and the elbows flexed to 90 degrees, the same positioning used for photographs. The patient is placed on the operating table in a supine position with the arms abducted at least 90 degrees and the markings are confirmed. Skin prepping should include the circumference of the proximal forearm, arm, shoulder, axilla, and midback. Drapes should be placed accordingly. The distal forearm and hands should be draped circumferentially with sterile towels or stockinettes so there is freedom of movement and access to the whole arm and axilla without contaminating the sterile field (Figure 4). Figure 4. View largeDownload slide Intraoperative photograph of a 65-year-old woman undergoing a brachioplasty using a “L-shape scar pattern.” The patient is positioned supine with the arms abducted 90 degrees and prepped circumferentially including shoulders, lateral chest, and axilla to midforearm. The arm is free and can be moved without contamination of the sterile field. Figure 4. View largeDownload slide Intraoperative photograph of a 65-year-old woman undergoing a brachioplasty using a “L-shape scar pattern.” The patient is positioned supine with the arms abducted 90 degrees and prepped circumferentially including shoulders, lateral chest, and axilla to midforearm. The arm is free and can be moved without contamination of the sterile field. Scar length varies according to arm deformity. Limited incision brachioplasty confines the area of resection and scar to the axillary region, a technique championed by Pollack and colleagues for the treatment of axillary hidradenitis suppurativa.15 Inspired by Pollack’s work, in 2014 Reed published his experience with minimally invasive brachioplasty in 1200 cases utilizing a resection pattern where the final scar was confined to the hidden area of the axilla. A key point for the success of this procedure was that the most dependent portion of the upper mid arm from the humerous to the bottom of the hanging skin of the arm, should not measure more than 12 cm with the arm abducted at 90 degrees, otherwise a traditional approach should be considered.16 This procedure was commonly employed in conjunction with liposuction outside the resection area. In 2016, Hill described a liposuction assisted short-scar brachioplasty employed in 165 patients using liposuction combined with axillary and a small proximal arm incision to address minimal to moderate skin laxity. The conclusion was that their technique addressed appropriately the selected cases in the proximal arm if there is appropriately skin tone and quality.17 Traditional brachioplasty with bicipital groove scar placement with or without extension into the lateral chest wall is a commonly used approach. Medially placed incision patterns vary and include straight line scar, a “T” shape scar, “W” shape, an “L” shape, and “S” shape scar, sometimes including a Z-plasty in the axilla to prevent retraction.5,18-23 A medially placed scar usually extends from the distal arm to the dome of the axilla and can have different extension designs, commonly extending into the lateral chest wall as pioneered by Pitanguy.5 Traditional brachioplasty can be associated with liposuction of the arm. Bicipital groove incisions facilitate the arm positioning in the operating room table, the scar is easily hidden during arm abduction and it is unnoticeable from a posterior view.23,24 However, there is still controversy about what would be the optimal location for the scar placement. In 2013, Samra et al surveyed plastic surgeons, the general population, and former brachioplasty patients about the optimal scar placement. They found that a medially based straight scar is the most aesthetically acceptable option when performing a brachioplasty.25 Posterior scar brachioplasty is another commonly used incision design. The final scar lays within the brachial sulcus.15,26-30 Proponents of this scar location point out that avoiding excision directly in the medial distal third of the arm might lead to a decreased risk for medial cutaneous sensory nerves injury as they branch and become superficial in this area. However, it is possible to injury the posterior branch of the medial brachial cutaneous nerve with this approach. Another argument for this approach is that the scar is less visible from the front with the arms abducted, although it is visible from the back view when the arms are relaxed. El Khatib proposed modifications of the posterior incision brachioplasty adding suspension to the flap to the deep fascia to try to prevent tension in the suture line, improve scar quality and visibility, and reduce scar migration.31 Posterior incision brachioplasty with severe skin laxity, such as after massive weight loss, can be extended into the axilla and the lateral chest wall to improve laxity in these areas. Some authors recommend using a Z-plasty in the axilla to avoid retraction, but this is not a unanimous approach. Figure 5 demonstrates commonly used scars and scar extensions. Figure 5. View largeDownload slide These photographs show a 39-year-old woman with the most commonly used scar patterns in brachioplasty. (A) Scar limited to the axillary fold. (B) “T” pattern scar, where the longitudinal scar is limited to the proximal arm. (C) Traditional bicipital groove scar, which can be combined with an axillary scar if needed. (D) Location of the brachial groove scar, which can also be extended into the axilla. (E) “L” pattern scar which can be extended into the lateral chest wall. (F) Extended brachial groove scar pattern. Figure 5. View largeDownload slide These photographs show a 39-year-old woman with the most commonly used scar patterns in brachioplasty. (A) Scar limited to the axillary fold. (B) “T” pattern scar, where the longitudinal scar is limited to the proximal arm. (C) Traditional bicipital groove scar, which can be combined with an axillary scar if needed. (D) Location of the brachial groove scar, which can also be extended into the axilla. (E) “L” pattern scar which can be extended into the lateral chest wall. (F) Extended brachial groove scar pattern. Suction-assisted liposuction (SAL), laser-assisted liposuction (LAL), ultrasound-assisted liposuction (UAL), and power-assisted liposuction (PAL) have been used for upper arm remodeling with or without associated skin excision.7,14,17,23,24,30,31 In 2012, Bossert et al published a level 3 study showing that liposuction can be performed safely and effectively in the posterior arm outside the region of excision at the time of brachioplasty. The authors performed traditional SAL to the liposuction sites. No statistically significant differences in complication rates were seen for the liposuction plus excision and the excision alone cohorts.32 A multipractice cohort study of 96 patients showed that liposuction is a commonly used to address arm contouring patient. They reported that 53.1% of patients had simultaneous circumferential arm liposuction at the time of brachioplasty.33 Liposuction has also been used in the excision area to debulk the subcutaneous tissue and allow for a very superficial skin resection, which may contribute to decreased rates of nerve injuries and seromas, due to preservation of the lymphatics of the upper arm.23,29,30,34 Either UAL, SAL, or PAL are commonly used for this purpose. There are no studies comparing efficacy of different liposuction modalities for arm contouring, and the decision about using different devices relies mostly on surgeon’s preference. Gentileschi et al evaluated the sensory nerve and the lymphatic drainage integrity of the upper limb after brachioplasty performed with SAL and a double ellipse superficial skin resection in 12 patients. Using Semmes-Weinstein monofilament test and indocyanine green lymphography protocols the authors concluded that their technique did not compromise the sensory or lymphatic integrity of the upper extremity.35 Fat grafting to the arms has also been added to liposuction to improve the arm aesthetics. Hoyos and Perez published their experience with ultrasound assisted liposuction and fat grafting in 651 patients.36 They found that high-definition liposculpture is a safe and effective method of arm contouring in conjunction with fat grafting. Patients with severe skin laxity were excluded. The total local complication rate was 3.2%. They advocate this treatment for anatomical definition of the arms including volumetric enhancement to correct deficiencies in specific areas of muscle bulk, such as in the deltoid area.36 According to the authors, major complications were avoided by limiting the volume of fat injections to 50 to 100 cc and using small cannulae (3 mm). Abboud et al published their experience with nonexcisional arm contouring in 95 patients utilizing PAL and lipofilling of the arms to obviate the need for skin excision. They proposed a new classifying system of brachial deformities including bicipital triangle depression and lipofilling of the medial arm to create a lifting effect of the posterior arm a treatment depending on patient’s presentation. Ideal candidates have minimal to moderate skin and fat excess with depression of the bicipital triangle.37 Radiofrequency-assisted liposuction has been used to induce skin contraction in patients with skin laxity to avoid visible scars. In 2011, a small pilot study showed statistically significant skin contraction in the upper arm region without the need for brachioplasty in patients with moderate and severe ptosis (grades 2b and 4). The average skin surface area contraction was 33.5% and the decrease in maximal arm laxity height was 50%. Patients with extreme lipodystrophy and severe ptosis did not show good results.38 In 2015, Leclere et al published a level 4 prospective review of 45 patients with Teimouriam grades I and II arm deformities that underwent 1 session of laser-assisted lipolysis (LAL). They found the procedure safe and reproducible, with statistically significant arm circumference reduction and skin retraction in all patients. They also found that all but one patient would recommend the treatment.39 In 2016, the same authors published another prospective study of 22 patients with Teimourian grades III and IV showing that laser assisted lipolysis is not a good modality for treatment in the population presenting with moderate to severe arm ptosis (Teimouriam grades III and IV).40 Chia et al also found quantifiable reductions in arm skin surface after radiofrequency assisted liposuction using a second generation radiofrequency device and subsequent PAL in 10 patients. Results were comparable to superficial liposuction using SAL and PAL on the patient’s opposite arm. There were no reported complications in both groups.41 Wound Closure It is known that the risk of development of hypertrophic or unfavorable scars is markedly reduced by a tension-free closure. Other evidence-based methods that have shown to improve scars are eversion of the wound edge, the use of occlusive dressings such as silicone, glue, and tapping and sometimes early treatment of red scars with pulse dye laser.42 The skin of the upper arm is particularly thin and prone to open wounds and scar hypertrophy specially in the massive weight loss patient with poor tissue quality. Attempts to improve wound healing and scar quality in brachioplasty include a combination of wound closure strategies to reduce tension and postoperative scar treatment. Most authors describe a two- or three-layer wound closure with absorbable sutures, usually polidioxanone suture, Vycril, or Monocryl depending on surgeon’s preference. The use of SFS anchoring sutures with layered closure as advocated by Lockwood has been used along the years to control the scar position,6 but this maneuver has its limitations due to the poor quality of this specific area. Despite all the attempts routinely made to improve scars, there are no data in the brachioplasty literature showing improvement in scar quality by using specific sutures, silicone ointment, or mechanical scar therapy. However, it is of common practice to use a sound wound closure technique and to reinforce the incision line with glue and skin adhesives to reduce tissue tension and stabilize the skin incision. Although no particular suture material has been found to be superior to others in the closure of brachioplasties, some argue the advantage of the barbed material is expediency and decreased operative times with low complication rates for all body contouring procedures including brachioplasty.43,44 A randomized multicenter trial compared the use of barbed sutures and conventional closure in abdominoplasty and breast surgery and found that barbed sutures enabled faster dermal closure than smooth sutures with comparable complication profile when a fast absorbing barbed suture was used.45 Since brachioplasties are often performed in combination with other aesthetic procedures, expediting anesthesia time can be of a great overall benefit to the patient. Fast closure is important in the arm to avoid excessive tissue swelling and secondary deformities. Excessive arm swelling can occur after tissue manipulation such as liposuction and can prevent primary wound closure, which is devastating for the patient and the surgeon. Therefore, staged resection and sequential closure of the arm is a common strategy applied by several authors. If resection by skin striping is applied, meticulous skin marking before incision is advised. Many experts advocate that the inability of closing the wound should be part of the informed consent for brachioplasty.12 There is no consensus about use of compression dressings as part of the postoperative care. However, most authors report the use of compressive dressings or elastic garments in the immediate postoperative period in hopes to improve swelling and healing. The use of drains in brachioplasty seems to depend on surgeon’s preference and extension of dissection. A retrospective review showed that the use of postoperative suction drainage did not decrease the rates of seroma.33 High levels of evidence showing that drains decrease seromas in brachioplasty are not available. Nonsurgical Modalities Use of Cryolipolysis Nonsurgical modalities for improvement of arm contour have expanded over the last decade. In 2010, the FDA has cleared the use of cryolipolysis (Coolsculpting by Zeltiq, Pleasanton, CA) to target discrete localized fat in the body such as flanks and abdomen. A large comprehensive retrospective review published in 2013 demonstrated the safety and efficacy of cryolipolysis for those areas.46 Most recently a Canadian study evaluated the safety and efficacy of contoured cup cryolipolysis specifically for arm fat with a prototype designed to maximize tissue contact with the cooling surface to improve comfort and simultaneously reduce treatment time by 25 minutes. Posttreatment ultrasound measurements in this group found a mean fat layer reduction of 3.2 mm confirmed clinically by blinded independent photo reviews.47 Cryolipolysis has been reserved for patients with arm fat but little or no skin laxity, since the treatment is not designed to treat excess skin. However, Stevens reported two cases of skin tightening after abdominal cryolipolysis and anecdotally estimates that improvement in skin appearance happens to 25% of patients in his practice.48 Further studies are needed to define the role of cryolipolysis as a potential skin tightening procedure. Use of Radiofrequency Noninvasive radiofrequency (RF) is a common treatment for skin laxity through induction of tissue damage by controlled heating, causing collagen denaturation and neocollagenesis.49 Nonablative radiofrequency devices have been used for skin tightening for more than a decade.50 These modalities produce a controlled rise in tissues temperature through a high frequency alternating current. Although there are many studies on this subject, most lack good methodological quality, have small samples, and are not clinical trials, which prevents decision making about the effectiveness and the actual role of RF in skin laxity of the face and body.51 Newer radiofrequency technologies were developed over the last few years to allow better monitoring of skin temperature and energy delivery for optimal tissue treatment and better outcomes. In 2016, Wu et al published a prospective case series evaluating the safety and efficacy of a thermistor-controlled monopolar radiofrequency device (ThermiRF, Almirall, Irvine, CA) for tightening of posterior arm skin laxity in 11 patients. They found skin laxity improvement in all patients through patient self-assessment scores and nonblinded evaluator assessments at 30 and 90 days.52 Unfortunately, the current studies lack standardization of the use of radiofrequency waves (range, 0.3-10 MHz), thermal power setting, and postoperative evaluation time. Studies with higher levels of evidence and larger samples are needed to define the role of RF in the treatment of arm laxity and establish protocols for use and treatment algorithms. Use of Focused Ultrasound Intense focused ultrasound has also been used as a noninvasive skin-tightening treatment for the face and body (Ulthera, Mesa, AZ). The device causes microthermal zones of coagulation as deep as 7.8 mm with sparing of the epidermis.53 In 2012, Alster and Tanzi published a small study determining the clinical efficacy of this treatment on the upper arms, extensor knees, and medial thighs (6 patients treated in each group). Endpoints were evaluated by blinded reviewers and were skin tightening and lifting by perceived cumulative smoothing of skin wrinkling, reduction of tissue bulk, and improvement of skin contour from 0 to 6 months. All patients demonstrated significant improvement of the three body zones with minor side effects and mild sedation was used to control mild to moderate discomfort during treatment.54 Studies with higher levels of evidence and larger samples are still needed to define the role of both radiofrequency and intense focused ultrasound in the treatment of arm laxity. Complications and Their Management Minor and major complications after brachioplasty have been reported to be as high as 56% and include infection, hematoma, seroma, wound dehiscence, hypertrophic scars, sensory nerve injury, and recurrent skin laxity.11,13,27,33,43 Appropriate preoperative counseling and establishment of reasonable expectations are very important considerations in the arm contouring population, especially in the massive weight loss. The likelihood of a secondary operation and the high rate of revisions should be discussed beforehand and be part of the informed consent. Egrari also mentions the difficult management of constrictive arm bands and the residual posterior distal arm lipodystrophy in the massive weight loss population, and emphasizes the need for an appropriate discussion about these issues with the patient before surgery.44 A recent large prospective study utilizing the CosmetAssure databank looked at 2294 patients that underwent brachioplasty over a period of 5 years. This study looked at major postoperative complications only, defined as events occurring within 30 days of operation requiring hospital admission, emergency room visit, or reoperation including hematoma, infection, pulmonary, and cardiac complications. All complications which were able of being managed in the clinic were excluded. The authors identified a 3.4% major complication rate with brachioplasty alone, most commonly infection in 1.7% and hematoma in 1.1%. When brachioplasty was performed in combination with other cosmetic procedures (66.8% of the cases) the overall complication rate increased to 4.4%. Combined procedures and male gender were independent findings for increased risk of hematoma (RR = 12.42 and RR = 8.89, respectively). Body mass index (BMI) ≥30 kg/m2 was an independent factor for increased risk of infection (RR = 1.96). This cohort also found that infection rates are higher in the brachioplasty population when compared with all other cosmetic surgery procedures (1.7% vs 0.4%).55 Minor complications are defined differently according to different authors and include hypertrophic scarring, wound dehiscence, asymmetry, and recurrence of skin laxity. A brachioplasty outcome study published by Zomerlei et al describes that the most common brachioplasty complication from their multipractice cohort was hypertrophic scarring in 24% of the cases. They considered hypertrophic scar requiring surgical revision a major complication. There was an 8.3% rate of surgical revision despite optimal closure and postoperative conservative measures such as laser therapy and steroid injections.33 CONCLUSION Brachioplasty is a growing procedure in plastic surgery. The literature approaching this topic shows overall good results and good patient satisfaction. Most papers focus on efforts to modify or improve the techniques to decrease scars and complications while offering good outcomes to the patients. The most important points to remember are: 1) Classification systems help stratify deformities to select the ideal treatment modalities based on fat and skin excess and the location and extension of the scars. 2) Liposuction, either SAL, PAL, or UAL are used alone or in association with skin resection, either in the excision site or circumferentially. No studies have shown the superiority of any technique in arm contouring. 3) Noninvasive fat removal and skin tightening have shown improvement of arm contour for mild arm changes in small studies. Higher levels of evidence are needed to show clear indication for different technologies and devices. 4) Infection and hematoma are the most common major complications of brachioplasty. Male gender is an independent factor for risk of hematoma and BMI ≥30 kg/m2 is an independent risk factor for infection. 5) Unfavorable scars in brachioplasty are a common cause of postoperative revisions. A combination of wound closure techniques to reduce tension and the addition of postoperative scar treatment are strategies that may help improve outcomes. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the US government. Dr. Yan Ortiz-Pomales is a military service member (or employee of the US government). This work was prepared as part of his official duties. Title 17, USC, x105 provides that “Copyright protection under this title is not available for any work of the U.S. Government.” Title 17, USC, x101 defines a US government work as a work prepared by a military service member or employee of the US government as part of that person’s official duties. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Cosmetic Surgery National Data Bank Statistics . Aesthet Surg J . 2017 ; 37 ( suppl_2 ): 1 - 29 . 2. American Society of Metabolic and Bariatric Surgery . 2016 . http://asmbs.org/resources/estimate-of-bariatric-surgery-numbers. Accessed June 2016 . 3. Thorek M . Esthetic surgery of the pendulous breast, abdomen and arms in females . Illinois Medical Journal . 1930 ; 348 - 357 . 4. Correa-Iturraspe M , Fernandez JC . Dermolipectomia braquial . Prensa Med Argent . 1954 ; 34 : 2432 - 2435 . 5. Pitanguy I . Dermolipectomy of the abdominal wall, thigh, buttocks and upper extremity . In: JM Converse Reconstructive Plastic Surgery . 2nd ed . Philadelphia, PA : WB Saunders 1977 ; 190 - 198 . 6. Lockwood T . Brachioplasty with superficial fascial system suspension . Plast Reconstr Surg . 1995 ; 96 ( 4 ): 912 - 920 . Google Scholar CrossRef Search ADS PubMed 7. Teimourian B , Malekzadeh S . Rejuvenation of the upper arm . Plast Reconstr Surg . 1998 ; 102 ( 2 ): 545 - 551 ; discussion 552. Google Scholar CrossRef Search ADS PubMed 8. Avelar J . Regional distribution and behavior of the subcutaneous tissue concerning selection and indication for liposuction . Aesthetic Plast Surg . 1989 ; 13 ( 3 ): 155 - 165 . Google Scholar CrossRef Search ADS PubMed 9. Chowdhry S , Elston JB , Lefkowitz T , Wilhelmi BJ . Avoiding the medial brachial cutaneous nerve in brachioplasty: an anatomical study . Eplasty . 2010 ; 29 : 10e . 10. Knoetgen J III , Moran SL . Long-term outcomes and complications associated with brachioplasty: a retrospective review and cadaveric study . Plast Reconstr Surg . 2006 ; 117 ( 7 ): 2219 - 2223 . Google Scholar CrossRef Search ADS PubMed 11. Gray’s Anatomy . 35th British Edition. W.B. Saunders Company . 1973 . 12. Aly A , Rubin J , Vogt P . Panell: Technical considerations: Techniques for arms . Plastic Surgery Education Foundation DVD from Body Contouring After Massive Weight Loss Symposium . Santa Fé, New Mexico . 2005 . 13. Appelt EA , Janis JE , Rohrich RJ . An algorithmic approach to upper arm contouring . Plast Reconstr Surg . 2006 ; 118 ( 1 ): 237 - 246 . Google Scholar CrossRef Search ADS PubMed 14. El Khatib HA . 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Ann Plast Surg . 1982 ; 9 ( 6 ): 498 - 501 . Google Scholar CrossRef Search ADS PubMed 20. de Souza Pinto EB , Erazo PJ , Matsuda CA et al. Brachioplasty technique with the use of molds . Plast Reconstr Surg . 2000 ; 105 ( 5 ): 1854 - 1860 ; discussion 1861. Google Scholar CrossRef Search ADS PubMed 21. Aboul-Wafa AM . S-shaped brachioplasty: an effective technique to correct excess skin and fat of the upper arm . Plast Reconstr Surg . 2013 ; 131 ( 4 ): 661e - 663e . Google Scholar CrossRef Search ADS PubMed 22. Hurwitz DJ , Holland SW . The L brachioplasty: an innovative approach to correct excess tissue of the upper arm, axilla, and lateral chest . Plast Reconstr Surg . 2006 ; 117 ( 2 ): 403 - 411 ; discussion 412. Google Scholar CrossRef Search ADS PubMed 23. Pascal JF , Le Louarn C . Brachioplasty . Aesthetic Plast Surg . 2005 ; 29 ( 5 ): 423 - 429 ; discussion 430. Google Scholar CrossRef Search ADS PubMed 24. Huemer GM . Some thoughts on the posterior brachioplasty . Plast Reconstr Surg . 2011 ; 127 ( 6 ): 2516 - 2517 ; author reply 2517. Google Scholar CrossRef Search ADS PubMed 25. Samra S , Samra F , Liu YJ , Sawh-Martinez R , Persing J . Optimal placement of a brachioplasty scar: a survey evaluation . Ann Plast Surg . 2013 ; 71 ( 4 ): 329 - 332 . Google Scholar CrossRef Search ADS PubMed 26. Knoetgen J 3rd , Moran SL . Long-term outcomes and complications associated with brachioplasty: a retrospective review and cadaveric study . Plast Reconstr Surg . 2006 ; 117 ( 7 ): 2219 - 2223 . Google Scholar CrossRef Search ADS PubMed 27. Aly A , Pace D , Cram A . Brachioplasty in the patient with massive weight loss . Aesthet Surg J . 2006 ; 26 ( 1 ): 76 - 84 . Google Scholar CrossRef Search ADS PubMed 28. Aly A , Soliman S , Cram A . Brachioplasty in the massive weight loss patient . Clin Plast Surg . 2008 ; 35 ( 1 ): 141 - 147 ; discussion 149. Google Scholar CrossRef Search ADS PubMed 29. Nguyen AT , Rohrich RJ . Liposuction-assisted posterior brachioplasty: technical refinements in upper arm contouring . Plast Reconstr Surg . 2010 ; 126 ( 4 ): 1365 - 1369 . Google Scholar CrossRef Search ADS PubMed 30. Shermak MA . Aesthetic refinements in body contouring in the massive weight loss patient: Part 2. Arms . Plast Reconstr Surg . 2014 ; 134 ( 5 ): 726e - 735e . Google Scholar CrossRef Search ADS PubMed 31. Elkhatib H . Posterior Scar Brachioplasty with Fascial Suspension: A Long-term Follow-up of a Modified Technique . Plast Reconstr Surg Glob Open . 2013 ; 1 ( 6 ): e38 . Google Scholar CrossRef Search ADS PubMed 32. Bossert RP , Dreifuss S , Coon D et al. Liposuction of the arm concurrent with brachioplasty in the massive weight loss patient: is it safe ? Plast Reconstr Surg . 2013 ; 131 ( 2 ): 357 - 365 . Google Scholar CrossRef Search ADS PubMed 33. Zomerlei TA , Neaman KC , Armstrong SD et al. Brachioplasty outcomes: a review of a multipractice cohort . Plast Reconstr Surg . 2013 ; 131 ( 4 ): 883 - 889 . Google Scholar CrossRef Search ADS PubMed 34. Hurwitz D . Brachioplasty . Clin Plast Surg . 2014 ; 41 ( 4 ): 745 - 751 . Google Scholar CrossRef Search ADS PubMed 35. Gentileschi S , Servillo M , Ferrandina G , Salgarello M . Lymphatic and Sensory Function of the Upper Limb After Brachioplasty in Post-Bariatric Massive Weight Loss Patients . Aesthet Surg J . 2017 ; 37 ( 9 ): 1022 - 1031 . Google Scholar CrossRef Search ADS PubMed 36. Hoyos A , Perez M . Arm dynamic definition by liposculpture and fat grafting . Aesthet Surg J . 2012 ; 32 ( 8 ): 974 - 987 . Google Scholar CrossRef Search ADS PubMed 37. Abboud MH , Abboud NM , Dibo SA . Brachioplasty by power-assisted liposuction and fat transfer: A novel approach that obviates skin excision . Aesthet Surg J . 2016 ; 36 ( 8 ): 908 - 917 . Google Scholar CrossRef Search ADS PubMed 38. Duncan DI . Improving outcomes in upper arm liposuction: adding radiofrequency-assisted liposuction to induce skin contraction . Aesthet Surg J . 2012 ; 32 ( 1 ): 84 - 95 . Google Scholar CrossRef Search ADS PubMed 39. Leclère FM , Alcolea JM , Vogt P et al. Laser-assisted lipolysis for arm contouring in Teimourian grades I and II: a prospective study of 45 patients . Lasers Med Sci . 2015 ; 30 ( 3 ): 1053 - 1059 . Google Scholar CrossRef Search ADS PubMed 40. Leclère FM , Alcolea JM , Vogt PM et al. Laser-assisted lipolysis for arm contouring in Teimourian grades III and IV: A prospective study involving 22 patients . Plast Surg (Oakv) . 2016 ; 24 ( 1 ): 35 - 40 . Google Scholar PubMed 41. Chia CT , Theodorou SJ , Hoyos AE , Pitman GH . Radiofrequency-assisted liposuction compared with aggressive superficial, subdermal liposuction of the arms: A bilateral quantitative comparison . Plast Reconstr Surg Glob Open . 2015 ; 3 ( 7 ): e459 . Google Scholar CrossRef Search ADS PubMed 42. Khansa I , Harrison B , Janis JE . Evidence-based scar management: How to improve results with technique and technology . Plast Reconstr Surg . 2016 ; 138 ( 3 Suppl ): 165S - 178S . Google Scholar CrossRef Search ADS PubMed 43. Duscher D , Pollhammer MS , Wenny R , Shamiyeh A , Schmidt M , Huemer GM . Barbed sutures in body-contouring: Outcome analysis of 695 procedures in 623 patients and technical advances . Aesthetic Plast Surg . 2016 ; 40 ( 6 ): 815 - 821 . Google Scholar CrossRef Search ADS PubMed 44. Egrari S . Brachioplasty: A personal approach . Aesthet Surg J . 2016 ; 36 ( 2 ): 193 - 203 . Google Scholar CrossRef Search ADS PubMed 45. Rubin JP , Hunstad JP , Polynice A et al. A multicenter randomized controlled trial comparing absorbable barbed sutures versus conventional absorbable sutures for dermal closure in open surgical procedures . Aesthet Surg J . 2014 ; 34 ( 2 ): 272 - 283 . Google Scholar CrossRef Search ADS PubMed 46. Stevens WG , Pietrzak LK , Spring MA . Broad overview of a clinical and commercial experience with CoolSculpting . Aesthet Surg J . 2013 ; 33 ( 6 ): 835 - 846 . Google Scholar CrossRef Search ADS PubMed 47. Carruthers JD , Humphrey S , Rivers JK . Cryolipolysis for reduction of arm fat: Safety and efficacy of a prototype coolcup applicator with flat contour . Dermatol Surg . 2017 ; 43 ( 7 ): 940 - 949 . Google Scholar CrossRef Search ADS PubMed 48. Stevens WG . Does cryolipolysis lead to skin tightening? A first report of cryodermadstringo . Aesthet Surg J . 2014 ; 34 ( 6 ): NP32 - NP34 . Google Scholar CrossRef Search ADS PubMed 49. Zelickson BD , Kist D , Bernstein E et al. Histological and ultrastructural evaluation of the effects of a radiofrequency-based nonablative dermal remodeling device: a pilot study . Arch Dermatol . 2004 ; 140 ( 2 ): 204 - 209 . Google Scholar CrossRef Search ADS PubMed 50. Fitzpatrick R , Geronemus R , Goldberg D , Kaminer M , Kilmer S , Ruiz-Esparza J . Multicenter study of noninvasive radiofrequency for periorbital tissue tightening . Lasers Surg Med . 2003 ; 33 ( 4 ): 232 - 242 . Google Scholar CrossRef Search ADS PubMed 51. Araújo AR , Soares VP , Silva FS , Moreira Tda S . Radiofrequency for the treatment of skin laxity: mith or truth . An Bras Dermatol . 2015 ; 90 ( 5 ): 707 - 721 . Google Scholar CrossRef Search ADS PubMed 52. Wu DC , Liolios A , Mahoney L , Guiha I , Goldman MP . Subdermal radiofrequency for skin tightening of the posterior upper arms . Dermatol Surg . 2016 ; 42 ( 9 ): 1089 - 1093 . Google Scholar CrossRef Search ADS PubMed 53. White WM , Makin IR , Barthe PG , Slayton MH , Gliklich RE . Selective creation of thermal injury zones in the superficial musculoaponeurotic system using intense ultrasound therapy: a new target for noninvasive facial rejuvenation . Arch Facial Plast Surg . 2007 ; 9 ( 1 ): 22 - 29 . Google Scholar CrossRef Search ADS PubMed 54. Alster TS , Tanzi EL . Noninvasive lifting of arm, thigh, and knee skin with transcutaneous intense focused ultrasound . Dermatol Surg . 2012 ; 38 ( 5 ): 754 - 759 . Google Scholar CrossRef Search ADS PubMed 55. Nguyen L , Gupta V , Afshari A , Shack RB , Grotting JC , Higdon KK . Incidence and risk factors of major complications in brachioplasty: Analysis of 2,294 patients . Aesthet Surg J . 2016 ; 36 ( 7 ): 792 - 803 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Arm Contouring: Review and Current Concepts

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© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
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1090-820X
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Abstract

Abstract Arm contour improvement is a desired goal of the massive weight loss and the aging population who want to maintain the arm aesthetics. Brachioplasty is a growing and safe procedure to improve the arm contour and different approaches and innovative treatment options have been described since the 1930s. This paper reviews the relevant literature in arm contouring including surgical and nonsurgical procedures used to aesthetically improve the arm. A comprehensive literature review was performed using the words “brachioplasty,” “arm lift,” “arm contouring,” “arm liposuction,” “noninvasive arm lift,” “minimally invasive arm lift.” Commonly used techniques, classification systems, and procedure outcomes are described. The review demonstrated that there are several methods to accomplish good arm contouring. There is no consensus about the best incision type and location, but the classification systems help guide treatment. Assessment of fat excess, skin excess, and location of the deformity (proximal, entire arm, arm and chest) help determine the best approach including liposuction only, skin resection only, a combination of liposuction and excision, or even the use of nonsurgical devices. Infection, hematoma, and unsatisfactory scars are the most commonly reported complications. Brachioplasty is a growing procedure and can be performed with low complication rates and good patient satisfaction. Classification systems stratify deformities to the ideal treatment but no studies have shown the superiority of any technique. Nonsurgical fat removal and skin tightening of the arms are promising procedures for selected patients and higher levels of evidence are needed to show clear indication for different technologies and devices. Learning Objectives The reader is presumed to have basic knowledge and understanding of arm anatomy pertinent to arm contouring procedures. After reading this review, the reader should be able to: Identify a suitable candidate for arm contouring procedures. Discuss common techniques and potential pitfalls of different arm contouring procedures including surgical and non-surgical modalities. Identify potential risks and benefits of arm contouring procedures. The American Society for Aesthetic Plastic Surgery (ASAPS) members and Aesthetic Surgery Journal (ASJ) subscribers can complete this Continuing Medical Education (CME) examination online by logging on to the CME portion of ASJ’s website (http://asjcme.oxfordjournals.org) and then searching for the examination by subject or publication date. Physicians may earn 1 AMA PRA Category 1 Credit by successfully completing the examination based on the article. The American Society for Aesthetic Plastic Surgery estimates a total of 24,622 brachioplasty procedures were performed in 2016, a fourfold increase since the year 2001.1 Also in 2016, the American Society for Metabolic and Bariatric Surgery reported approximately 200,000 bariatric surgeries and these numbers are estimated to continue to rise annually.2 As bariatric surgery becomes the surgical standard of care for the treatment of metabolic disease, it is logical to assume that the numbers of body contouring procedures will continue to grow. Arm contour improvement is a desired feature not only of the massive weight loss population but also of the aging population who want to maintain the arm aesthetics. The objective of this paper is to review the relevant anatomy, surgical techniques, and outcomes in brachioplasty and minimally invasive arm contouring procedures. Historical Perspective As the field of body contouring surgery parallels the staggering numbers of bariatric procedures done worldwide, the techniques addressing the excess skin and fat of the upper arm continue to evolve. The evolution and aesthetic refinements in technique have made this surgery a safe procedure, due to a better understanding of anatomy, preventions of potential nerve injuries during resection, and several technological advancements. The idea of sculpting the arms of excess skin and fat is not novel. In the 1930s Thorek popularized an elliptical excision of the medial upper arm as the preferred technique for brachioplasty at that time.3 Aesthetic arm contouring refinements were then published by Correa-Iturraspe and Fernandez in 1954.4 In the 1970s Lewis modified the procedure by adding a Z-plasty to address issues of scar contracture, and in the same decade, Pitanguy added the extended approach of the axillary and arm skin excess through one single incision.5 In 1995, Lockwood published his landmark article regarding the superficial fascial system as a supportive structure of the arm and its role in arm contouring surgery, concepts that have since become one of the principles applied to brachioplasty procedures.6 In 1998, Teimourian and Malekzadeh published the first classification system of the degree of severity of arm deformity with a corresponding surgical treatment that could provide the best aesthetic result.7 Relevant Anatomy The youthful appearance of the arm depends on skin quality, adipose tissue distribution, and muscle shape. The skin of the medial arm is thinner than other body parts and therefore prone to early wrinkling. The subcutaneous layer is divided into superficial (alveolar) and deep (lamellar) layers, and the deeper layer is more prone to fat accumulation than the superficial layer, mostly in the posterior arm.8 The superficial fascial system (SFS) described by Lockwood supports the posteromedial arm as a sling, and is contiguous with the clavipectoral and axillary fascia. This mechanism fails with aging or significant weight loss, leading to ptosis of the posteromedial arm. Deeper into the subcutaneous layers, muscles and deep neurovascular structures are involved by the deep fascia. Just superficial to the deep fascia are the medial brachial and antebrachial cutaneous nerves, major sensory nerves that innervate medial arm, the elbow, and the proximal forearm. These sensory nerves arise from the medial cord of the brachial plexus and travel superficially to the deep fascia along the basilic vein in the distal third of the arm. Sensory branches are most often encountered 7 to 14 cm proximal to the medial epicondyle and can be easily damaged during dissection of the distal arm (Figure 1). Careful superficial dissection in this location, leaving a layer of fat over the deep fascia, can help prevent nerve injury.9-11 The lymphatic system follows the course of the venous systems and drains into the axillary lymph nodes.11 Superficial dissection can also help preserve of the lymphatic network and improve seroma formation. Figure 1. View largeDownload slide Diagram showing the arm anatomy relevant to brachioplasty, which includes the estimated location of the neurovascular structures including the cutaneous nerves. Red: brachial artery (deep plane); blue: basilic vein, the anatomic landmark for medial antebrachial cutaneous nerve identification. Figure 1. View largeDownload slide Diagram showing the arm anatomy relevant to brachioplasty, which includes the estimated location of the neurovascular structures including the cutaneous nerves. Red: brachial artery (deep plane); blue: basilic vein, the anatomic landmark for medial antebrachial cutaneous nerve identification. Preoperative Assessment A thorough history and physical examination, including evaluation of the whole circumference of the arm with the arms abducted and elbows flexed at 90 degrees to obtain maximal tissue relaxation. Establishing clear patient expectations and scar tolerance is paramount for brachioplasty, since the scar can be very visible for several months to years after surgery. Preferred scar location can be discussed with the patient, and some authors advocate drawing a preview of the scar on the arms a few days before surgery to help patients have realistic expectations about location and length of the scar.12 Frontal, oblique, and posterior views should include the upper trunk since deformities of the arms can extend into the axillary and lateral chest area (Figure 2). Figure 2. View largeDownload slide These photographs show a 39-year-old woman in standard (A) frontal, (B) oblique, (C) and posterior preoperative pictures for brachioplasty patient. Frontal, oblique, and posterior views should include the axilla and lateral chest wall to document laxity in those areas. Figure 2. View largeDownload slide These photographs show a 39-year-old woman in standard (A) frontal, (B) oblique, (C) and posterior preoperative pictures for brachioplasty patient. Frontal, oblique, and posterior views should include the axilla and lateral chest wall to document laxity in those areas. Classification systems are helpful to guide treatment selection during preoperative assessment. It includes assessment of fat excess, skin excess, and location of the deformity (proximal, entire arm, arm and chest) and treatment options vary between liposuction only, skin resection only, a combination of liposuction and excision, or possibly the use of newer skin tightening devices. Table 1 shows the 3 most commonly used classification systems of arm deformities and strategy for treatment. Teimourian and Malekzadeh described the first classification system, dividing patients into 4 groups. Deformities and treatment escalade from group 1 to 4, from minimal to moderate adiposity, suitable for liposuction alone to traditional brachioplasty for patients with extensive laxity.7 Appelt et al expanded the classification system to include location of skin excess, and added the indication for extended brachioplasty to severe deformities encompassing the arm and lateral chest wall.13 El Khatib’s classification of brachial ptosis is similar to the previous ones but also includes measurement of the amount of skin laxity below the brachial sulcus from no ptosis to >10 cm to improve the strategy for treatment.14Figure 3 illustrates different groups of deformities. Table 1. Classification of Arm Deformities and Treatment Strategies. Adapted from Teimourian and Malekzadeh,7 Appelt et al,13 and El Khatib.14 Teimouriam and Malekzadeh Group Skin and fat excess Treatment I Minimal to moderate subcutaneous fat with minimal skin laxity Liposuction alone II Generalized accumulation of fat with moderate skin laxity Liposuction +/- axillary skin excision III Generalized obesity and extensive skin laxity Circumferential liposuction with proximal skin resection IV Minimal fat and extensive skin laxity Brachioplasty Appelt et al Group Skin and fat excess Treatment I Minimal skin, moderate fat Liposuction alone (UAL + SAL) IIa Moderate proximal skin, minimal fat Limited brachioplasty IIb Moderate entire arm skin, minimal fat Brachioplasty (possible L-shape extension) IIc Moderate arm and chest skin, minimal fat Extended brachioplasty IIIa Moderate proximal skin, moderate fat Staged liposuction or liposuction plus resection IIIb Moderate entire arm skin, moderate fat Staged liposuction or liposuction plus resection IIIc Moderate arm and chest skin, moderate fat Staged liposuction or liposuction plus resection El Khatib Group Skin and fat excess Treatment I Minimal fat deposit (<300 mL) with no ptosis Circumferential liposuction IIa Moderate fat deposit with grade 1 ptosis (<5 cm) Staged circumferential liposuction IIb Severe fat deposit with grade 2 ptosis (5-10 cm) Liposuction +/- axillary skin excision III Generalized obesity and extensive skin laxity Liposuction arm + short scar brachioplasty IV Minimal or no fat deposit with grade 3 ptosis Brachioplasty Teimouriam and Malekzadeh Group Skin and fat excess Treatment I Minimal to moderate subcutaneous fat with minimal skin laxity Liposuction alone II Generalized accumulation of fat with moderate skin laxity Liposuction +/- axillary skin excision III Generalized obesity and extensive skin laxity Circumferential liposuction with proximal skin resection IV Minimal fat and extensive skin laxity Brachioplasty Appelt et al Group Skin and fat excess Treatment I Minimal skin, moderate fat Liposuction alone (UAL + SAL) IIa Moderate proximal skin, minimal fat Limited brachioplasty IIb Moderate entire arm skin, minimal fat Brachioplasty (possible L-shape extension) IIc Moderate arm and chest skin, minimal fat Extended brachioplasty IIIa Moderate proximal skin, moderate fat Staged liposuction or liposuction plus resection IIIb Moderate entire arm skin, moderate fat Staged liposuction or liposuction plus resection IIIc Moderate arm and chest skin, moderate fat Staged liposuction or liposuction plus resection El Khatib Group Skin and fat excess Treatment I Minimal fat deposit (<300 mL) with no ptosis Circumferential liposuction IIa Moderate fat deposit with grade 1 ptosis (<5 cm) Staged circumferential liposuction IIb Severe fat deposit with grade 2 ptosis (5-10 cm) Liposuction +/- axillary skin excision III Generalized obesity and extensive skin laxity Liposuction arm + short scar brachioplasty IV Minimal or no fat deposit with grade 3 ptosis Brachioplasty SAL, suction-assisted liposuction; UAL, ultrasound-assisted liposuction View Large Table 1. Classification of Arm Deformities and Treatment Strategies. Adapted from Teimourian and Malekzadeh,7 Appelt et al,13 and El Khatib.14 Teimouriam and Malekzadeh Group Skin and fat excess Treatment I Minimal to moderate subcutaneous fat with minimal skin laxity Liposuction alone II Generalized accumulation of fat with moderate skin laxity Liposuction +/- axillary skin excision III Generalized obesity and extensive skin laxity Circumferential liposuction with proximal skin resection IV Minimal fat and extensive skin laxity Brachioplasty Appelt et al Group Skin and fat excess Treatment I Minimal skin, moderate fat Liposuction alone (UAL + SAL) IIa Moderate proximal skin, minimal fat Limited brachioplasty IIb Moderate entire arm skin, minimal fat Brachioplasty (possible L-shape extension) IIc Moderate arm and chest skin, minimal fat Extended brachioplasty IIIa Moderate proximal skin, moderate fat Staged liposuction or liposuction plus resection IIIb Moderate entire arm skin, moderate fat Staged liposuction or liposuction plus resection IIIc Moderate arm and chest skin, moderate fat Staged liposuction or liposuction plus resection El Khatib Group Skin and fat excess Treatment I Minimal fat deposit (<300 mL) with no ptosis Circumferential liposuction IIa Moderate fat deposit with grade 1 ptosis (<5 cm) Staged circumferential liposuction IIb Severe fat deposit with grade 2 ptosis (5-10 cm) Liposuction +/- axillary skin excision III Generalized obesity and extensive skin laxity Liposuction arm + short scar brachioplasty IV Minimal or no fat deposit with grade 3 ptosis Brachioplasty Teimouriam and Malekzadeh Group Skin and fat excess Treatment I Minimal to moderate subcutaneous fat with minimal skin laxity Liposuction alone II Generalized accumulation of fat with moderate skin laxity Liposuction +/- axillary skin excision III Generalized obesity and extensive skin laxity Circumferential liposuction with proximal skin resection IV Minimal fat and extensive skin laxity Brachioplasty Appelt et al Group Skin and fat excess Treatment I Minimal skin, moderate fat Liposuction alone (UAL + SAL) IIa Moderate proximal skin, minimal fat Limited brachioplasty IIb Moderate entire arm skin, minimal fat Brachioplasty (possible L-shape extension) IIc Moderate arm and chest skin, minimal fat Extended brachioplasty IIIa Moderate proximal skin, moderate fat Staged liposuction or liposuction plus resection IIIb Moderate entire arm skin, moderate fat Staged liposuction or liposuction plus resection IIIc Moderate arm and chest skin, moderate fat Staged liposuction or liposuction plus resection El Khatib Group Skin and fat excess Treatment I Minimal fat deposit (<300 mL) with no ptosis Circumferential liposuction IIa Moderate fat deposit with grade 1 ptosis (<5 cm) Staged circumferential liposuction IIb Severe fat deposit with grade 2 ptosis (5-10 cm) Liposuction +/- axillary skin excision III Generalized obesity and extensive skin laxity Liposuction arm + short scar brachioplasty IV Minimal or no fat deposit with grade 3 ptosis Brachioplasty SAL, suction-assisted liposuction; UAL, ultrasound-assisted liposuction View Large Figure 3. View largeDownload slide Diagrams illustrating different arm deformities. (A) Minimal skin laxity and no fatty deposits. Potential candidate for nonsurgical skin tightening procedure. (B) Moderate skin laxity in the proximal third of the arm with minimal fatty deposits. Potential candidate for limited axillary fold scar or a “T” pattern scar with the longitudinal limb limited to the proximal arm. (C) Moderate skin laxity and moderate fatty deposits. Potential candidate for a traditional brachial groove or bicipital groove brachioplasty and arm liposuction. (D) Severe skin laxity that extends into the lateral chest wall. Potential candidate for an extended brachioplasty. Figure 3. View largeDownload slide Diagrams illustrating different arm deformities. (A) Minimal skin laxity and no fatty deposits. Potential candidate for nonsurgical skin tightening procedure. (B) Moderate skin laxity in the proximal third of the arm with minimal fatty deposits. Potential candidate for limited axillary fold scar or a “T” pattern scar with the longitudinal limb limited to the proximal arm. (C) Moderate skin laxity and moderate fatty deposits. Potential candidate for a traditional brachial groove or bicipital groove brachioplasty and arm liposuction. (D) Severe skin laxity that extends into the lateral chest wall. Potential candidate for an extended brachioplasty. Surgical Technique There are many described techniques to accomplish a sound aesthetic result in brachioplasty and consequently there is no consensus on the ideal approach, scar placement, or short vs extended scar techniques. As shown on Table 1, a common guide for defining the ideal brachioplasty technique for different patients is the assessment of the amount of skin laxity and amount of fat excess. There are also variations on scar positioning and use of associated liposuction among different authors. The most common proposed techniques involve skin excision alone, excision associated with liposuction, or liposuction alone. These algorithms share similarities and aim to qualify the amount of skin and fat excess and correlate the different presentations with optimal surgical approaches. Preoperative markings are made with the shoulders abducted to 90 degrees and the elbows flexed to 90 degrees, the same positioning used for photographs. The patient is placed on the operating table in a supine position with the arms abducted at least 90 degrees and the markings are confirmed. Skin prepping should include the circumference of the proximal forearm, arm, shoulder, axilla, and midback. Drapes should be placed accordingly. The distal forearm and hands should be draped circumferentially with sterile towels or stockinettes so there is freedom of movement and access to the whole arm and axilla without contaminating the sterile field (Figure 4). Figure 4. View largeDownload slide Intraoperative photograph of a 65-year-old woman undergoing a brachioplasty using a “L-shape scar pattern.” The patient is positioned supine with the arms abducted 90 degrees and prepped circumferentially including shoulders, lateral chest, and axilla to midforearm. The arm is free and can be moved without contamination of the sterile field. Figure 4. View largeDownload slide Intraoperative photograph of a 65-year-old woman undergoing a brachioplasty using a “L-shape scar pattern.” The patient is positioned supine with the arms abducted 90 degrees and prepped circumferentially including shoulders, lateral chest, and axilla to midforearm. The arm is free and can be moved without contamination of the sterile field. Scar length varies according to arm deformity. Limited incision brachioplasty confines the area of resection and scar to the axillary region, a technique championed by Pollack and colleagues for the treatment of axillary hidradenitis suppurativa.15 Inspired by Pollack’s work, in 2014 Reed published his experience with minimally invasive brachioplasty in 1200 cases utilizing a resection pattern where the final scar was confined to the hidden area of the axilla. A key point for the success of this procedure was that the most dependent portion of the upper mid arm from the humerous to the bottom of the hanging skin of the arm, should not measure more than 12 cm with the arm abducted at 90 degrees, otherwise a traditional approach should be considered.16 This procedure was commonly employed in conjunction with liposuction outside the resection area. In 2016, Hill described a liposuction assisted short-scar brachioplasty employed in 165 patients using liposuction combined with axillary and a small proximal arm incision to address minimal to moderate skin laxity. The conclusion was that their technique addressed appropriately the selected cases in the proximal arm if there is appropriately skin tone and quality.17 Traditional brachioplasty with bicipital groove scar placement with or without extension into the lateral chest wall is a commonly used approach. Medially placed incision patterns vary and include straight line scar, a “T” shape scar, “W” shape, an “L” shape, and “S” shape scar, sometimes including a Z-plasty in the axilla to prevent retraction.5,18-23 A medially placed scar usually extends from the distal arm to the dome of the axilla and can have different extension designs, commonly extending into the lateral chest wall as pioneered by Pitanguy.5 Traditional brachioplasty can be associated with liposuction of the arm. Bicipital groove incisions facilitate the arm positioning in the operating room table, the scar is easily hidden during arm abduction and it is unnoticeable from a posterior view.23,24 However, there is still controversy about what would be the optimal location for the scar placement. In 2013, Samra et al surveyed plastic surgeons, the general population, and former brachioplasty patients about the optimal scar placement. They found that a medially based straight scar is the most aesthetically acceptable option when performing a brachioplasty.25 Posterior scar brachioplasty is another commonly used incision design. The final scar lays within the brachial sulcus.15,26-30 Proponents of this scar location point out that avoiding excision directly in the medial distal third of the arm might lead to a decreased risk for medial cutaneous sensory nerves injury as they branch and become superficial in this area. However, it is possible to injury the posterior branch of the medial brachial cutaneous nerve with this approach. Another argument for this approach is that the scar is less visible from the front with the arms abducted, although it is visible from the back view when the arms are relaxed. El Khatib proposed modifications of the posterior incision brachioplasty adding suspension to the flap to the deep fascia to try to prevent tension in the suture line, improve scar quality and visibility, and reduce scar migration.31 Posterior incision brachioplasty with severe skin laxity, such as after massive weight loss, can be extended into the axilla and the lateral chest wall to improve laxity in these areas. Some authors recommend using a Z-plasty in the axilla to avoid retraction, but this is not a unanimous approach. Figure 5 demonstrates commonly used scars and scar extensions. Figure 5. View largeDownload slide These photographs show a 39-year-old woman with the most commonly used scar patterns in brachioplasty. (A) Scar limited to the axillary fold. (B) “T” pattern scar, where the longitudinal scar is limited to the proximal arm. (C) Traditional bicipital groove scar, which can be combined with an axillary scar if needed. (D) Location of the brachial groove scar, which can also be extended into the axilla. (E) “L” pattern scar which can be extended into the lateral chest wall. (F) Extended brachial groove scar pattern. Figure 5. View largeDownload slide These photographs show a 39-year-old woman with the most commonly used scar patterns in brachioplasty. (A) Scar limited to the axillary fold. (B) “T” pattern scar, where the longitudinal scar is limited to the proximal arm. (C) Traditional bicipital groove scar, which can be combined with an axillary scar if needed. (D) Location of the brachial groove scar, which can also be extended into the axilla. (E) “L” pattern scar which can be extended into the lateral chest wall. (F) Extended brachial groove scar pattern. Suction-assisted liposuction (SAL), laser-assisted liposuction (LAL), ultrasound-assisted liposuction (UAL), and power-assisted liposuction (PAL) have been used for upper arm remodeling with or without associated skin excision.7,14,17,23,24,30,31 In 2012, Bossert et al published a level 3 study showing that liposuction can be performed safely and effectively in the posterior arm outside the region of excision at the time of brachioplasty. The authors performed traditional SAL to the liposuction sites. No statistically significant differences in complication rates were seen for the liposuction plus excision and the excision alone cohorts.32 A multipractice cohort study of 96 patients showed that liposuction is a commonly used to address arm contouring patient. They reported that 53.1% of patients had simultaneous circumferential arm liposuction at the time of brachioplasty.33 Liposuction has also been used in the excision area to debulk the subcutaneous tissue and allow for a very superficial skin resection, which may contribute to decreased rates of nerve injuries and seromas, due to preservation of the lymphatics of the upper arm.23,29,30,34 Either UAL, SAL, or PAL are commonly used for this purpose. There are no studies comparing efficacy of different liposuction modalities for arm contouring, and the decision about using different devices relies mostly on surgeon’s preference. Gentileschi et al evaluated the sensory nerve and the lymphatic drainage integrity of the upper limb after brachioplasty performed with SAL and a double ellipse superficial skin resection in 12 patients. Using Semmes-Weinstein monofilament test and indocyanine green lymphography protocols the authors concluded that their technique did not compromise the sensory or lymphatic integrity of the upper extremity.35 Fat grafting to the arms has also been added to liposuction to improve the arm aesthetics. Hoyos and Perez published their experience with ultrasound assisted liposuction and fat grafting in 651 patients.36 They found that high-definition liposculpture is a safe and effective method of arm contouring in conjunction with fat grafting. Patients with severe skin laxity were excluded. The total local complication rate was 3.2%. They advocate this treatment for anatomical definition of the arms including volumetric enhancement to correct deficiencies in specific areas of muscle bulk, such as in the deltoid area.36 According to the authors, major complications were avoided by limiting the volume of fat injections to 50 to 100 cc and using small cannulae (3 mm). Abboud et al published their experience with nonexcisional arm contouring in 95 patients utilizing PAL and lipofilling of the arms to obviate the need for skin excision. They proposed a new classifying system of brachial deformities including bicipital triangle depression and lipofilling of the medial arm to create a lifting effect of the posterior arm a treatment depending on patient’s presentation. Ideal candidates have minimal to moderate skin and fat excess with depression of the bicipital triangle.37 Radiofrequency-assisted liposuction has been used to induce skin contraction in patients with skin laxity to avoid visible scars. In 2011, a small pilot study showed statistically significant skin contraction in the upper arm region without the need for brachioplasty in patients with moderate and severe ptosis (grades 2b and 4). The average skin surface area contraction was 33.5% and the decrease in maximal arm laxity height was 50%. Patients with extreme lipodystrophy and severe ptosis did not show good results.38 In 2015, Leclere et al published a level 4 prospective review of 45 patients with Teimouriam grades I and II arm deformities that underwent 1 session of laser-assisted lipolysis (LAL). They found the procedure safe and reproducible, with statistically significant arm circumference reduction and skin retraction in all patients. They also found that all but one patient would recommend the treatment.39 In 2016, the same authors published another prospective study of 22 patients with Teimourian grades III and IV showing that laser assisted lipolysis is not a good modality for treatment in the population presenting with moderate to severe arm ptosis (Teimouriam grades III and IV).40 Chia et al also found quantifiable reductions in arm skin surface after radiofrequency assisted liposuction using a second generation radiofrequency device and subsequent PAL in 10 patients. Results were comparable to superficial liposuction using SAL and PAL on the patient’s opposite arm. There were no reported complications in both groups.41 Wound Closure It is known that the risk of development of hypertrophic or unfavorable scars is markedly reduced by a tension-free closure. Other evidence-based methods that have shown to improve scars are eversion of the wound edge, the use of occlusive dressings such as silicone, glue, and tapping and sometimes early treatment of red scars with pulse dye laser.42 The skin of the upper arm is particularly thin and prone to open wounds and scar hypertrophy specially in the massive weight loss patient with poor tissue quality. Attempts to improve wound healing and scar quality in brachioplasty include a combination of wound closure strategies to reduce tension and postoperative scar treatment. Most authors describe a two- or three-layer wound closure with absorbable sutures, usually polidioxanone suture, Vycril, or Monocryl depending on surgeon’s preference. The use of SFS anchoring sutures with layered closure as advocated by Lockwood has been used along the years to control the scar position,6 but this maneuver has its limitations due to the poor quality of this specific area. Despite all the attempts routinely made to improve scars, there are no data in the brachioplasty literature showing improvement in scar quality by using specific sutures, silicone ointment, or mechanical scar therapy. However, it is of common practice to use a sound wound closure technique and to reinforce the incision line with glue and skin adhesives to reduce tissue tension and stabilize the skin incision. Although no particular suture material has been found to be superior to others in the closure of brachioplasties, some argue the advantage of the barbed material is expediency and decreased operative times with low complication rates for all body contouring procedures including brachioplasty.43,44 A randomized multicenter trial compared the use of barbed sutures and conventional closure in abdominoplasty and breast surgery and found that barbed sutures enabled faster dermal closure than smooth sutures with comparable complication profile when a fast absorbing barbed suture was used.45 Since brachioplasties are often performed in combination with other aesthetic procedures, expediting anesthesia time can be of a great overall benefit to the patient. Fast closure is important in the arm to avoid excessive tissue swelling and secondary deformities. Excessive arm swelling can occur after tissue manipulation such as liposuction and can prevent primary wound closure, which is devastating for the patient and the surgeon. Therefore, staged resection and sequential closure of the arm is a common strategy applied by several authors. If resection by skin striping is applied, meticulous skin marking before incision is advised. Many experts advocate that the inability of closing the wound should be part of the informed consent for brachioplasty.12 There is no consensus about use of compression dressings as part of the postoperative care. However, most authors report the use of compressive dressings or elastic garments in the immediate postoperative period in hopes to improve swelling and healing. The use of drains in brachioplasty seems to depend on surgeon’s preference and extension of dissection. A retrospective review showed that the use of postoperative suction drainage did not decrease the rates of seroma.33 High levels of evidence showing that drains decrease seromas in brachioplasty are not available. Nonsurgical Modalities Use of Cryolipolysis Nonsurgical modalities for improvement of arm contour have expanded over the last decade. In 2010, the FDA has cleared the use of cryolipolysis (Coolsculpting by Zeltiq, Pleasanton, CA) to target discrete localized fat in the body such as flanks and abdomen. A large comprehensive retrospective review published in 2013 demonstrated the safety and efficacy of cryolipolysis for those areas.46 Most recently a Canadian study evaluated the safety and efficacy of contoured cup cryolipolysis specifically for arm fat with a prototype designed to maximize tissue contact with the cooling surface to improve comfort and simultaneously reduce treatment time by 25 minutes. Posttreatment ultrasound measurements in this group found a mean fat layer reduction of 3.2 mm confirmed clinically by blinded independent photo reviews.47 Cryolipolysis has been reserved for patients with arm fat but little or no skin laxity, since the treatment is not designed to treat excess skin. However, Stevens reported two cases of skin tightening after abdominal cryolipolysis and anecdotally estimates that improvement in skin appearance happens to 25% of patients in his practice.48 Further studies are needed to define the role of cryolipolysis as a potential skin tightening procedure. Use of Radiofrequency Noninvasive radiofrequency (RF) is a common treatment for skin laxity through induction of tissue damage by controlled heating, causing collagen denaturation and neocollagenesis.49 Nonablative radiofrequency devices have been used for skin tightening for more than a decade.50 These modalities produce a controlled rise in tissues temperature through a high frequency alternating current. Although there are many studies on this subject, most lack good methodological quality, have small samples, and are not clinical trials, which prevents decision making about the effectiveness and the actual role of RF in skin laxity of the face and body.51 Newer radiofrequency technologies were developed over the last few years to allow better monitoring of skin temperature and energy delivery for optimal tissue treatment and better outcomes. In 2016, Wu et al published a prospective case series evaluating the safety and efficacy of a thermistor-controlled monopolar radiofrequency device (ThermiRF, Almirall, Irvine, CA) for tightening of posterior arm skin laxity in 11 patients. They found skin laxity improvement in all patients through patient self-assessment scores and nonblinded evaluator assessments at 30 and 90 days.52 Unfortunately, the current studies lack standardization of the use of radiofrequency waves (range, 0.3-10 MHz), thermal power setting, and postoperative evaluation time. Studies with higher levels of evidence and larger samples are needed to define the role of RF in the treatment of arm laxity and establish protocols for use and treatment algorithms. Use of Focused Ultrasound Intense focused ultrasound has also been used as a noninvasive skin-tightening treatment for the face and body (Ulthera, Mesa, AZ). The device causes microthermal zones of coagulation as deep as 7.8 mm with sparing of the epidermis.53 In 2012, Alster and Tanzi published a small study determining the clinical efficacy of this treatment on the upper arms, extensor knees, and medial thighs (6 patients treated in each group). Endpoints were evaluated by blinded reviewers and were skin tightening and lifting by perceived cumulative smoothing of skin wrinkling, reduction of tissue bulk, and improvement of skin contour from 0 to 6 months. All patients demonstrated significant improvement of the three body zones with minor side effects and mild sedation was used to control mild to moderate discomfort during treatment.54 Studies with higher levels of evidence and larger samples are still needed to define the role of both radiofrequency and intense focused ultrasound in the treatment of arm laxity. Complications and Their Management Minor and major complications after brachioplasty have been reported to be as high as 56% and include infection, hematoma, seroma, wound dehiscence, hypertrophic scars, sensory nerve injury, and recurrent skin laxity.11,13,27,33,43 Appropriate preoperative counseling and establishment of reasonable expectations are very important considerations in the arm contouring population, especially in the massive weight loss. The likelihood of a secondary operation and the high rate of revisions should be discussed beforehand and be part of the informed consent. Egrari also mentions the difficult management of constrictive arm bands and the residual posterior distal arm lipodystrophy in the massive weight loss population, and emphasizes the need for an appropriate discussion about these issues with the patient before surgery.44 A recent large prospective study utilizing the CosmetAssure databank looked at 2294 patients that underwent brachioplasty over a period of 5 years. This study looked at major postoperative complications only, defined as events occurring within 30 days of operation requiring hospital admission, emergency room visit, or reoperation including hematoma, infection, pulmonary, and cardiac complications. All complications which were able of being managed in the clinic were excluded. The authors identified a 3.4% major complication rate with brachioplasty alone, most commonly infection in 1.7% and hematoma in 1.1%. When brachioplasty was performed in combination with other cosmetic procedures (66.8% of the cases) the overall complication rate increased to 4.4%. Combined procedures and male gender were independent findings for increased risk of hematoma (RR = 12.42 and RR = 8.89, respectively). Body mass index (BMI) ≥30 kg/m2 was an independent factor for increased risk of infection (RR = 1.96). This cohort also found that infection rates are higher in the brachioplasty population when compared with all other cosmetic surgery procedures (1.7% vs 0.4%).55 Minor complications are defined differently according to different authors and include hypertrophic scarring, wound dehiscence, asymmetry, and recurrence of skin laxity. A brachioplasty outcome study published by Zomerlei et al describes that the most common brachioplasty complication from their multipractice cohort was hypertrophic scarring in 24% of the cases. They considered hypertrophic scar requiring surgical revision a major complication. There was an 8.3% rate of surgical revision despite optimal closure and postoperative conservative measures such as laser therapy and steroid injections.33 CONCLUSION Brachioplasty is a growing procedure in plastic surgery. The literature approaching this topic shows overall good results and good patient satisfaction. Most papers focus on efforts to modify or improve the techniques to decrease scars and complications while offering good outcomes to the patients. The most important points to remember are: 1) Classification systems help stratify deformities to select the ideal treatment modalities based on fat and skin excess and the location and extension of the scars. 2) Liposuction, either SAL, PAL, or UAL are used alone or in association with skin resection, either in the excision site or circumferentially. No studies have shown the superiority of any technique in arm contouring. 3) Noninvasive fat removal and skin tightening have shown improvement of arm contour for mild arm changes in small studies. Higher levels of evidence are needed to show clear indication for different technologies and devices. 4) Infection and hematoma are the most common major complications of brachioplasty. Male gender is an independent factor for risk of hematoma and BMI ≥30 kg/m2 is an independent risk factor for infection. 5) Unfavorable scars in brachioplasty are a common cause of postoperative revisions. A combination of wound closure techniques to reduce tension and the addition of postoperative scar treatment are strategies that may help improve outcomes. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the US government. Dr. Yan Ortiz-Pomales is a military service member (or employee of the US government). This work was prepared as part of his official duties. Title 17, USC, x105 provides that “Copyright protection under this title is not available for any work of the U.S. Government.” Title 17, USC, x101 defines a US government work as a work prepared by a military service member or employee of the US government as part of that person’s official duties. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Cosmetic Surgery National Data Bank Statistics . Aesthet Surg J . 2017 ; 37 ( suppl_2 ): 1 - 29 . 2. American Society of Metabolic and Bariatric Surgery . 2016 . http://asmbs.org/resources/estimate-of-bariatric-surgery-numbers. 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Khansa I , Harrison B , Janis JE . Evidence-based scar management: How to improve results with technique and technology . Plast Reconstr Surg . 2016 ; 138 ( 3 Suppl ): 165S - 178S . Google Scholar CrossRef Search ADS PubMed 43. Duscher D , Pollhammer MS , Wenny R , Shamiyeh A , Schmidt M , Huemer GM . Barbed sutures in body-contouring: Outcome analysis of 695 procedures in 623 patients and technical advances . Aesthetic Plast Surg . 2016 ; 40 ( 6 ): 815 - 821 . Google Scholar CrossRef Search ADS PubMed 44. Egrari S . Brachioplasty: A personal approach . Aesthet Surg J . 2016 ; 36 ( 2 ): 193 - 203 . Google Scholar CrossRef Search ADS PubMed 45. Rubin JP , Hunstad JP , Polynice A et al. A multicenter randomized controlled trial comparing absorbable barbed sutures versus conventional absorbable sutures for dermal closure in open surgical procedures . Aesthet Surg J . 2014 ; 34 ( 2 ): 272 - 283 . Google Scholar CrossRef Search ADS PubMed 46. Stevens WG , Pietrzak LK , Spring MA . Broad overview of a clinical and commercial experience with CoolSculpting . Aesthet Surg J . 2013 ; 33 ( 6 ): 835 - 846 . Google Scholar CrossRef Search ADS PubMed 47. Carruthers JD , Humphrey S , Rivers JK . Cryolipolysis for reduction of arm fat: Safety and efficacy of a prototype coolcup applicator with flat contour . Dermatol Surg . 2017 ; 43 ( 7 ): 940 - 949 . Google Scholar CrossRef Search ADS PubMed 48. Stevens WG . Does cryolipolysis lead to skin tightening? A first report of cryodermadstringo . Aesthet Surg J . 2014 ; 34 ( 6 ): NP32 - NP34 . Google Scholar CrossRef Search ADS PubMed 49. Zelickson BD , Kist D , Bernstein E et al. Histological and ultrastructural evaluation of the effects of a radiofrequency-based nonablative dermal remodeling device: a pilot study . Arch Dermatol . 2004 ; 140 ( 2 ): 204 - 209 . Google Scholar CrossRef Search ADS PubMed 50. Fitzpatrick R , Geronemus R , Goldberg D , Kaminer M , Kilmer S , Ruiz-Esparza J . 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Noninvasive lifting of arm, thigh, and knee skin with transcutaneous intense focused ultrasound . Dermatol Surg . 2012 ; 38 ( 5 ): 754 - 759 . Google Scholar CrossRef Search ADS PubMed 55. Nguyen L , Gupta V , Afshari A , Shack RB , Grotting JC , Higdon KK . Incidence and risk factors of major complications in brachioplasty: Analysis of 2,294 patients . Aesthet Surg J . 2016 ; 36 ( 7 ): 792 - 803 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com

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Aesthetic Surgery JournalOxford University Press

Published: Mar 12, 2018

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